Sometime before 3:09 a.m. on Sept. 1, 2009, Jamal Miller began to tear the bedsheet in his room at the Illinois Youth Center in St. Charles.

The stocky 16-year-old tied the sheet to a sock and tied the sock around the metal bar at the top of his bunk bed. He attached three notes to the cinder-block wall with toothpaste and placed another piece of notebook paper in the narrow window of his door.

Since he first threatened to kill himself at age 8, Miller had been hospitalized half a dozen times for psychiatric problems and made at least four suicide attempts. By the time he ended up in the state's juvenile justice system, he had been shuttled in and out of juvenile detention and treatment so often that his mother couldn't remember the last time he celebrated a holiday or birthday at home.

Officials had placed Miller in a corrections facility for mentally ill inmates. But in August, after a psychologist concluded that his primary problem was "criminal thinking," he was transferred to a general-population institution in St. Charles. Less than four weeks later, he placed the torn sheet around his neck and hanged himself from his bed.

Miller's death was the seventh suicide in the state's juvenile correctional facilities in the past decade. Those deaths, as well as 175 serious suicide attempts during the same period, reflect a breakdown in the system that is supposed to rehabilitate and protect some of the state's most troubled and vulnerable young people, a Tribune investigation found.

Department officials estimate that about two-thirds of the 1,200 inmates in the state's eight juvenile justice facilities have been diagnosed with a mental illness and that half the young men and nearly all the young women have thought about or attempted suicide before they enter the system.

While it may be impossible to eliminate all suicide risks behind bars, the state has failed to take simple steps to protect these teenagers from themselves.

The type of metal-frame bunk bed that Miller used to hang himself, which has a sturdy bar across the top, had been involved in three other suicides since 2000 and in at least 21 attempts. But until Miller's death, a lack of urgency and political will kept the bunk beds from being removed. Although officials are now moving to replace them, metal-frame bunks still make up nearly 60 percent of the system's beds.

Other equipment and furnishings pose similar, overlooked hazards. Since 2000, three inmates have hanged themselves from air vent covers, the most recent case involving a model the department considers safe. At least three inmates since 2006 have tried to hang themselves from ceiling light fixtures at the youth center in Harrisburg. Another inmate tried to hang himself from a wall-mounted television stand at the Kewanee facility in February.

Investigations into the seven suicides have left key questions unanswered and failed to resolve inconsistencies in accounts of the deaths, interviews and a review of documents show. Not once did these investigations find fault with current procedures or staff, the Tribune found.

Nationally, suicides in juvenile institutions are relatively rare, but experts say it's crucial to take the threat seriously.

"You need to approach everyone in your care as though the risk of suicide is very, very significant," said Melissa Sickmund, who has studied the issue as chief of systems research at the National Center for Juvenile Justice.

"Yes, you can say that a kid who is determined to kill themselves will do it," Sickmund said. "But it shouldn't be that easy in prison."

Troubled childhood

The events of Jamal Miller's childhood read like a blur of signposts leading to trouble: He was born as his mother, a crack addict, faced murder charges; placed on Ritalin at age 4; suspended five times from second grade; drinking by age 8; and smoking marijuana at 9.

His first major psychiatric crisis occurred when, at 8, he threatened to kill himself after he was arrested for stealing a bike. He was admitted for two weeks to Rush-Presbyterian-St. Luke's Medical Center in Chicago, where doctors diagnosed him with depression and attention deficit hyperactivity disorder and noted that his "emotional life reflects a preoccupation with aggression, violence, and misbehavior."

Over the years, the diagnoses and the drugs would change — bipolar disorder, mood disorder, conduct disorder; Paxil, Risperdal, Zoloft — but Miller seemed unable to control his anger toward others or himself.

In seventh grade he was expelled for pulling a knife on another student. At 13, he was hospitalized after he tried to hang himself with a dog chain. He made another suicide attempt shortly before his 15th birthday, when he tried to suffocate himself by tying a pillow to his face while he was in a residential treatment program for mental illness and drug addiction.

"He used to always say, 'Mama, there's something wrong with me, and I don't know what it is,'" said his mother, Cheryl Miller, 42. "He'd say, 'I try so hard.'"

Cheryl Miller served 21/2 years in prison on a second-degree murder conviction for shooting a 16-year-old girl in the neck. She stayed clean for several years afterward but eventually started using crack cocaine again, even as she steadily worked jobs at fast-food restaurants and as a home health care aide, often pulling two shifts a day. She also faithfully attended her two sons' school meetings and, later, their court hearings. She looked for programs that might help them stay out of trouble.

"Every day she tried to make amends … to the boys in the best way that she could as she continued to go through her struggles," said Richard Wills, a veteran probation officer who worked with the family for more than five years. "That made that family kind of unique."

In July 2007, in the midst of a chaotic period when he ricocheted among hospitals, the Cook County Juvenile Temporary Detention Center and home, Jamal Miller sent his mother a poem he apparently had copied from a young-adult novel. Called "Poem of Hope," it concluded: "I cannot see the future/ and I cannot change the past/ but the present is so heavy/ I don't think I'm going to last." In the book, "Tears of a Tiger," the character who writes the poem ultimately commits suicide.

The next month, Miller pleaded guilty to attempted robbery and aggravated battery for breaking the nose of a teenager while trying to take money from him. Eight months later, after he got kicked out of a residential treatment center, he returned to court, where Judge Michael Stuttley offered Miller one last chance before sending him to juvenile prison: to join his mother in Springfield, where she had moved from Park Forest and, she said, kicked her crack addiction.

But in Springfield there was another suicide attempt, another hospitalization and then two arrests: for threatening to kill a teacher and threatening a police officer.

"I knew we had exhausted everything we could do at that point," Wills, the probation officer, recalled. "And not only did I know that, but Jamal knew it too."

Even as Wills reluctantly recommended that Miller be committed to the Illinois Department of Juvenile Justice, he thought the teenager still could turn himself around. He had seen it happen before.

In late November 2008, Miller was sent to the youth center in St. Charles, where he spent nine weeks in the special treatment unit. In February, officials transferred him to Kewanee, the facility for juvenile offenders with the most serious mental health issues. Shortly before the transfer, the treatment administrator at St. Charles described his mental health history as "significant but currently stable," noting that he had been on at least eight psychotropic medications and had five psychiatric hospitalizations.

Miller's record at Kewanee shows a series of fights and disciplinary problems. He also once threatened to commit suicide unless he could talk to a counselor, a threat he later said wasn't serious, and he was placed on suicide watch for two days after he assaulted another youth and told staff members: "I'm going to make it worse for myself." His assignment to the facility's dual mental health and substance abuse treatment program failed twice.

On June 19, a week after he was removed for the second time, a psychologist at Kewanee concluded that Miller didn't need drug abuse treatment or intensive mental health services.

"Youth's primary problem since his arrival to IDJJ is his criminal thinking, not mental illness," she wrote.

The next month, officials approved his transfer back to St. Charles. The request cited his "lack of immediate mental health needs or concerns."

The department stands by the reassessment of Miller and his transfer.

"Hindsight being 20/20, one could go back and second-guess their clinical decisions. I choose not to do that," said Juvenile Justice director Kurt Friedenauer. "Clinical staff and doctors were making those assessments … based on information they had available regarding the circumstances and previous history."

One expert who reviewed Miller's records at the Tribune's request said the reassessment "appeared to be an error in clinical judgment."

"There's overwhelming evidence he's got a serious psychological illness that needs to be carefully assessed and treated," said Dr. Bennett Leventhal, a nationally known child and adolescent psychiatrist who has worked on juvenile justice issues. "And to ignore that evidence is a mistake."

Juvenile justice and mental health experts have long questioned the availability and quality of mental health treatment at the state's youth facilities. Two days after Miller's death, Friedenauer, the department's director, asked the MacArthur Foundation's Models for Change initiative to lead a review of mental health needs and care throughout the system. That report is due soon.

Questions about mental health treatment also surround the suicide of 17-year-old Miguel Stone, who hanged himself at the Harrisburg youth center in 2004. He had made three suicide attempts in the previous 12 months, the most recent just three weeks before entering the downstate facility.

He told a therapist at Harrisburg that he wasn't planning to kill himself but also described his "lack of hope," records show. The day of his death, another inmate became concerned about Stone and asked the center's chaplain to visit him. Stone would not face him or speak to him. About 45 minutes later, he was found hanging from a sheet tied to the top of the bunk bed.

In Miller's case, he was transferred back to St. Charles on Aug. 5, 2009,and assigned to a special treatment unit. Inmates in special treatment at St. Charles receive about half the hours of mental health care as those in special treatment at Kewanee. Miller told a psychiatrist at St. Charles that he no longer needed psychiatric medication and refused to take it. Medical staff can force medication in certain circumstances, but the psychiatrist concluded that was not called for.

The afternoon before he killed himself, records state, Miller argued with one of the guards at St. Charles. For a troubled young man like Miller — described soon after he arrived in the juvenile system as someone whose "suicide gestures all appear to have been impulsive acts engaged in when youth is angry and frustrated" — that encounter would apparently be enough to tip him over the edge.

When Miller returned that night to his single room, it contained everything he would need to kill himself: a sheet and his bunk bed.

A decade of warnings

Corrections officials had received ample warning that the system's metal-frame bunk beds posed a suicide hazard. In January 2000, Jason Doke, 17, made a noose out of his belt and hanged himself from the top of his bunk at the state juvenile facility at Valley View. A year and a half later, Kene Tillman, 13, hanged himself from his bunk at St. Charles. Miguel Stone died the same way.

In the five years between Stone's and Miller's suicides, at least 21 other inmates in juvenile facilities tried to take their lives by hanging themselves from metal-frame bunks, records show.

At least one Department of Corrections investigator recognized the risk, though there is no evidence that he shared his concerns with anyone in the department. "A child could reach up there," investigator Richard Harrington testified at a coroner's inquest into Stone's death. "It's done quite easy."

After Miller's suicide, the John Howard Association, a local prison watchdog group, identified the bunks and other furnishings as suicide risks, saying the rooms at St. Charles were "rife with self-harm hazards.''

Air vent covers, which the association said should be replaced with breakaway models, are found across the juvenile system, officials say. Although light fixtures have been replaced in 119 rooms at Harrisburg, they remain in 171.

Friedenauer said that since the Department of Juvenile Justice was created in 2006, taking over the youth centers from the Department of Corrections, it has repeatedly sought money for safer equipment. The department's 2007 master plan also includes calls for safer rooms. But, Friedenauer said, former Gov. Rod Blagojevich and state legislators never allocated the money.

"We've time and time again reiterated the safety issue," Friedenauer said.

Benjamin Wolf, the associate legal director of the American Civil Liberties Union of Illinois, which has studied the state's juvenile justice system, said the department and its inmates have suffered because they have long been a "low priority" for the governor and the legislature.

"These kids have about as little clout as you can possibly have, so getting money for them is difficult," Wolf said. "They're from poor families. They've committed crimes. They're mentally ill. They don't vote. So they're at the back of the line."

Although experts say the Juvenile Justice Department has improved care for young offenders, Gov. Pat Quinn recently proposed folding it into the Illinois Department of Children and Family Services.

After Miller's death, juvenile justice officials made an emergency request for money to replace the bunks; Quinn's administration responded with $2.5 million for upgrades, including new beds. Friedenauer said he hopes all the bunks will be gone later this year, except those in dormitory-style rooms where inmates are less able to attempt suicide without being detected.

That comes too late for Miller, who sometime before his death on Sept. 1 signaled his intentions and his despair in the piece of paper he placed in the window of his door.

The Tribune reported these stories by reviewing thousands of pages of court papers, prison records, medical and psychiatric records, and other documents, as well as conducting dozens of interviews. The newspaper obtained many documents through the state's Freedom of Information Act. Other documents, including confidential prison and mental health records, were obtained with the cooperation of inmates' family members, who shared documents they had obtained and made open records requests to the Department of Juvenile Justice. The reporters petitioned Cook County Juvenile Court for records involving Jamal Miller.

Since 2000, seven inmates of the state's youth centers have committed suicide. A Tribune investigation found that officials failed to remove furnishings that were suicide hazards and did not thoroughly investigate the deaths.